IntroductionUp to a third of all elderly patients in nursing

The data suggest that the risk of mortality with these drugs is generally increased with higher doses and seems to be highest for haloperidol and least for quetiapine.IntroductionUp to a third of all elderly patients in nursing homes are treated with antipsychotic drugs.1 2 3 4 5 In the past, inappropriate prescribing of antipsychotics in nursing homes has primarily been considered a marker of suboptimal care.6 7 Federal action thus focused primarily on defining and enforcing specific diagnostic criteria for the initiation and monitoring of these drugs (Omnibus Budget Reconciliation Act).8 In recent years, evidence has accumulated that their use is a drug safety issue as well. After earlier warnings of increased risks of cerebrovascular events (with risperidone, olanzapine, and aripiprazole),9 the Food and Drug Administration issued an advisory warning in 2005 that atypical antipsychotics were associated with a 60 70% increased risk of death compared with placebo in randomised controlled trials among older patients with dementia, and black box warnings were added to the labels of all atypical drugs.10 Subsequent studies found risks at least as high among users of conventional antipsychotics,11 12 13 and the Food and Drug Administration issued a similar warning for such drugs in 2008.14Despite these strong safety warnings, use of antipsychotic drugs in nursing homes is likely to remain substantial as evidenced by the recent audit by the US Department of Health and Human Services15 because of the continued growth in the number of people with dementia, the perceived need for some type of intervention in patients with severe persistent symptoms, and a paucity of effective alternative pharmacological or behavioural approaches.16 Questions about the comparative safety of individual antipsychotic drugs are therefore of paramount importance to patients and prescribers, but the existing Food and Drug Administration advisories do not distinguish between drugs in these classes and thus offer no guidance in that regard.In the absence of randomised trials, surveillance data from large longitudinal healthcare databases provide a unique opportunity to examine the comparative safety of individual drugs, provided that rigorous methodological approaches are applied to minimise bias. Such databases also include the most vulnerable segments of the population, such as residents of nursing homes, who are commonly excluded from trials.We investigated whether the risk of overall and cause specific mortality is equal across antipsychotic drugs or whether there are regimens with safety advantages that should be prescribed preferentially in older residents of nursing homes.MethodsData source and study cohortThe study cohort was drawn from a merged dataset of Medicaid and Medicare claims pandora jewellery, the minimum data set (MDS), the Online Survey Certification and Reporting (OSCAR) system, and the National Death Index in 45 states in the United States (all except Arizona, Delaware, Nevada, Oregon, and Rhode Island) for 2001 5.

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